Contraceptive use remains low in Nigeria, with only 11% of
women reporting use of any modern method. Access to long-acting reversible
contraceptives (LARCs) is constrained by a severe shortage of human resources.
To assess feasibility of task shifting provision of implants, we trained
community health extension workers (CHEWs) to insert and remove contraceptive
implants in rural communities of Bauchi and Sokoto states in northern Nigeria.
We conducted 2- to 3-week training sessions for 166 selected
CHEWs from 82 facilities in Sokoto state (September 2013) and 84 health
facilities in Bauchi state (December 2013). To assess feasibility of the task
shifting approach, we conducted operations research using a pretest–posttest
design using multiple sources of information, including surveys with 151
trained CHEWs (9% were lost to follow-up) and with 150 family planning clients;
facility observations using supply checklists (N = 149); direct observation of
counseling provided by CHEWs (N = 144) and of their clinical (N = 113) skills;
as well as a review of service statistics (N = 151 health facilities). The
endline assessment was conducted 6 months after the training in each state.
CHEWs inserted a total of 3,588 implants in 151 health
facilities over a period of 6 months, generating 10,088 couple-years of
protection (CYP). After practicing on anatomic arm models, most CHEWs achieved
competency in implant insertions after insertions with 4–5 actual clients.
Clinical observations revealed that CHEWs performed implant insertion tasks
correctly 90% of the time or more for nearly all checklist items. The amount of
information that CHEWs provided clients increased between baseline and endline,
and over 95% of surveyed clients reported being satisfied with CHEWs’ services
in both surveys. The study found that supervisors not only observed and
corrected insertion skills, as needed, during supervisory visits but also
encouraged CHEWs to conduct more community mobilization to generate client
demand, thereby promoting access to quality services. CHEWs identified a lack
of demand in the communities as the major barrier for providing services.
With adequate training and supportive supervision, CHEWs in
northern Nigeria can provide high-quality implant insertion services. If more
CHEWs are trained to provide implants and greater community outreach is
conducted to generate demand, uptake of LARCs in Nigeria may increase.
Below: A family planning client from Bauchi state receives counseling on Jadelle implants by a Community Health Extension Worker (CHEW). Observation of counseling sessions confirmed that CHEWs provided accurate and complete information.
Below: A Community Health Extension Worker (CHEW) at Dorowa Dispensary, Dambam LGA, in Bauchi state, practices inserting contraceptive implants on an arm model. After achieving competency on the arm model, CHEWs inserted implants under supervision on actual clients.
Below: A male Community Health Extension Worker (CHEW) from Muzuwa Dispensary, Dambam LGA, in Bauchi state, inserts a contraceptive implant. Over 40% of the CHEWs in the pilot task shifting study were men, revealing the acceptance of male providers by women to deliver implant services.
By: Zulfiya Charyeva,
a Olugbenga Oguntunde,a,b Nosa Orobaton,b,c Emmanuel Otolorin,b,d Fatima Inuwa,b,d Olubisi Alalade,b,d Dele Abegunde,b,c and Saba’atu Danladia,b
bTargeted States High Impact Project (TSHIP), Bauchi, Nigeria
cJSI Research & Training Institute, Arlington, VA, USA
d
aPalladium, Washington, DC, USA
bTargeted States High Impact Project (TSHIP), Bauchi, Nigeria
cJSI Research & Training Institute, Arlington, VA, USA
dJhpiego – an affiliate of Johns Hopkins University, Abuja, Nigeria
Corresponding
author.
